Tag: sensitivity

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Don’t Skimp On Sensitivity!

sensitivity

In radiology, almost anything can change our sensitivity to detecting disease. Problems with electronics and hardware such as PACS, the RIS, imaging software, or even dictation software can cause us to miss out on information. Phone calls and texts can interrupt our train of thought. Many of these problems can be beyond our control. But, there are also ways that we are directly responsible for our daily reads that can affect our sensitivity. So, what are some main ways radiologists can knowingly skimp on sensitivity to negatively affect patient care?

Not Getting Priors- A Template For Decreasing Sensitivity

Out of all the ways we can negatively affect patient care, this one likely has the most bang for the buck. Whether we need to search for changes that can affect chemotherapeutic regimens or determine if a pulmonary embolus is acute or chronic, we can severely decrease pathology detection and change patient management when we neglect priors. It is certainly worth the extra time to look at the prior studies!

Not Reading The Prior Reports

Just as critically, it is not just about searching the priors but also about reading the previous reports. I can’t tell you how often I have discovered items in the information that are the reason for performing the following study that may not be so obvious if you don’t read the prior dictation in addition to looking at it. It could be an incidental tiny pancreatic cyst or a subtle rib sclerotic rib lesion that you might not realize by just skimming the previous images . In either case, you must also make sure to peruse the prior reports to maximize sensitivity.

Using The Correct Software For Imaging

It is effortless to skimp on interpreting images when the programs are slow or unwieldy. However, we are obligated to look at studies in a way that will maximize sensitivity. That may involve looking at a PET scan on the appropriate interpretation platform or using the reconstruction software for coronary artery CTAs. If you skimp on this step, you are much more likely to miss disease that can negatively affect patient management.

Windowing/Protocols

It is much easier to go through a study if you don’t take the time to go through bone and liver windows on a CT scan or neglect the diffusion-weighted sequences on an MRI of the abdomen. However, by forgoing these steps, you are also sacrificing sensitivity. Sure, it’s nice to get home a bit earlier. But is it worth the outcome of missing a liver lesion or a hidden enlarged abdominal mesenteric lymph node?

Not Waiting For All The Images To Arrive

I get impatient when the computer sends the studies over slowly. That happens to almost everyone once in a while. And, it is very tempting to interpret the images based on the images that you have alone. But, for instance, axial CT scans images without the coronals, and sagittal can cause you to miss compression fractures, renal masses, and more. Don’t skimp on the waiting for these last images to cross over.

Skimping on Sensitivity!

We, radiologists, have taken a Hippocratic oath. This oath obliges us to do no harm. Although we are under pressure to complete all our cases, we must best answer the clinical question appropriately without sacrificing sensitivity. Or else the study can become worthless or, even worse, harmful to the patient. So, make sure to cross all your t’s and dot all your i’s by checking for priors, using the correct software, looking at all the windows/sequences, and not being impatient before interpretation. These are simple ways to increase our sensitivity and ultimately improve patient care!

 

 

 

 

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The Magic Of Priors

magic

As I was scrolling through the worklist, I came across a case with priors that significantly changed the disposition of a patient, emphasizing the magic of priors. A chest CTA showed numerous pulmonary emboli sitting in multiple branches of the pulmonary arteries. At first glance, any radiologist would be ready to pick up the phone and call the ER to let them know about the pulmonary emboli. Of course, this patient would most likely need anti-coagulation and possibly thrombolysis. But then, at the very end of the list of prior studies, I noticed a previous chest CTA from 2017. To my surprise, the images looked the same. Those bilateral pulmonary emboli were most likely chronic! No new treatment would likely be necessary. If you want to talk about why priors are so important, this is an excellent example of why. It entirely changed the management of this patient. And it is the proverbial tip of the iceberg. So, if you ever get that feeling of laziness, here are some reasons it pays to take the time to press on and look at the patient’s prior studies.

Increases Sensitivity

No, it is not cheating to look at the prior report. Instead, it is excellent patient care. Some lesions, for instance, pancreatic lesions, can be very subtle. And, if you don’t look back at the prior report and the prior study, you are much more likely to miss it. You may neglect to recommend follow-up on this sort of lesion. And, in this case, you never know what can happen next. It can grow and need further treatment or not. Regardless, why not increase your chances of picking up significant findings?

Increases Specificity

Let’s give the example of that lowly nonspecific liver lesion that we always seem to find. The second time around, the diagnosis can become a lot more specific. If the lesion has been stable for the past ten years, it is highly likely to not be malignant. And, you have made of critical management decision of leaving the lesion alone. Otherwise, a whole workup can ensue, wasting health care dollars and causing potential psychological discomfort to the patient. These issues happen all the time, so don’t forget to compare to the priors.

The Magic Of Priors Changes Patient Treatment

I can’t tell you how often I get calls from oncologists that fail to give us the most recent priors, subsequently add them to our system, and then request an addendum. Why is that, you might ask? Well, most oncologists know the value of comparing to priors. How would you know whether to continue on a chemotherapeutic regimen or not? In an imaging study, learning if there is improvement, stability, or progression takes the guesswork of how to treat the patient next. And this is not to mention the potential life-saving acute issues I mentioned with the chronic PE case at the beginning!

Increases Referring Physician Confidence

Knowing that you have an eye on the previous study on all your reports allows your referrers to feel comfortable that you are safely and methodically correctly interpreting images. Of course, this step can lead to a virtuous circle. You get more patients referred because you increase clinician confidence and patient well-being. And, you earn a better living. It’s all good!

The Magic Of Priors

One of the big life lessons of practicing radiology for so many years is to avoid neglecting prior studies. I have seen one too many cases slip through the cracks, and I certainly don’t want the same to happen on my watch. And, I am sure that you probably don’t want that on yours. So remember why the magic of priors is so essential- increasing sensitivity and specificity, changing patient management, and increasing clinician confidence. And, you should make it part of your standard protocol never to forget to look at them too!

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Should Radiology Residents Be Chronic Overcallers?

overcallers

In an ideal world, radiologists, in particular, would like to get all the cases right all the time. But, in reality, we know that can never happen since radiologists are people. And, we deal with imperfect technologies. Some findings will go undetected, and others misinterpreted. But that is the way of the world.

So what can we control? Well, we can adjust our sensitivities. Increasing our sensitivity allows us to make more findings at the expense of causing all our patients to receive too many additional tests. Subsequently, they would receive elevated doses of radiation and too many biopsies.

Decreasing our sensitivity sets us up for missing findings. These same misses can lead radiologists down the path of patient care issues and lawsuits. So, we continually set our internal thermometers to call cases toward either overcalling or under calling to get to that perfect mean. And, radiology residents must learn to do the same.

How Do We Adjust Our Internal Thresholds?

So, what causes us to change our sensitivities and become overcallers? Well, have you had a recent lawsuit or a bad mistake? You probably will overcall a bit for fear of missing findings. Do you have a large population with healthy hearts and read cardiac nucs. You probably are under calling a patient’s cardiac disease, knowing that most patients have none.

Additionally, we are continually tweaking our internal standards all the time. Should we call that skin fold over the chest as a pneumothorax? Or, is there a trace subarachnoid hemorrhage near the calvarial fracture site? These are the questions that we face daily. And how we choose to answer them affects the patient care we deliver.

What About Radiology Residents Versus Attendings?

Moreover, radiologists and radiology residents practice in two alternative universes. And, their pitfalls differ substantially. To that point, what can dramatically affect an attending’s care can barely impact a resident and vice versa. For instance, chronically overcalling lung nodules on chest films as an attending can anger your referrers. In a worst-case scenario, a practice may even decide to fire overcallers over the issue.

On the other hand, it may be desirable to overcall those same nodules as a resident. Your attending may want you to call the finding to alert them to whether it should make a clinical difference. She can always discard it in the final report if it does not change management.

So, Where Should Residents Lie Within The Spectrum During Residency?

In general, under calling as a resident, can be particularly dangerous for many reasons. First and foremost, residents have a lack of experience upon which to rely. After your 10,000th case of pneumonia, you will have probably have seen enough to almost instinctually know what most types of pneumonia look like on a chest film. Residents don’t have that background on which to make a judgment. So, when you don’t call pneumonia, you are more likely going to miss the signs of one.

Second, the hazards of under calling far outweigh the benefits of overcalling. If you are on an overnight shift and you are not sure whether your patient has a bleed, you can cause much more damage by sending the patient home with a bleed. The consequences of keeping the patient in the hospital with that more sensitive call are much less devastating. This philosophy goes for most serious disease entities.

And then finally, you make your attendings happier when you overcall rather than under call. I would much rather see a resident make all the findings of equivocal tiny nodules and questionable hepatic cysts. Although part of the spectrum as overcallers, these residents make findings that can help me to pick up lesions I may miss as a radiology attending. A pair of second overly sensitive eyes can be an excellent accessory screening tool to ensure that the radiologist does not miss the findings as well.

Chronic Overcalling Can Lead To A Difficult Attending Transition

But, this chronic overcalling can lead to a problem at your first attending gig. You have accustomed yourself to overcalling findings as a resident. Now, as radiology faculty, that same sensitivity point may not work well to allow you to flourish in your career. But, you have worked at this threshold level for a while. Not so easy. Habits die hard. We see this issue all the time with new radiologists.

What’s The Point Of This Conversation About Overcallers?

Well, residents need to be aware of their thresholds for making findings. Yes, it is worth it to start as overcallers based on less experience and the consequences of missing critical diagnoses. But, be wary about maintaining the same thresholds as you move along in your career. Be mindful of slowly trying to increase your limits for detection over time using your increasing experience and knowledge. The goal is to get you closer to the perfect sensitivity in an endless asymptotic curve. So, be ready to adjust your approach as an attending. It may save your career!